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Sports/Injuries

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Dean Wade

Kansas State has advanced to the Sweet 16 for the first time in eight years. They play Kentucky on Thursday in Atlanta, but will they have one of their star players Dean Wade?
Wade, a 6-foot-10, all-Big 12, averaging over 16 points per game in the regular season, suffered a stress fracture in his left foot in against TCU in the quarterfinals of the conference tournament on March 8. He has been held in reserve as a precautionary measure, watching his team advance in March Madness to the Sweet 16 from the bench.
As for returning to the court? Wade recently said, “I am 98% sure I will play. I don’t know if they can keep me out of this one”, noting that he has been feeling better each day. He has been ready to jump onto the court when called upon in case of emergency, but the team has not needed it yet. Against their upcoming opponent Kansas? They might. But Kansas has had their own injuries.

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Jarred Vanderbilt

The other bench is also dealing with foot and ankle injuries. Jarred Vanderbilt, a 6-foot-9 McDonald’s All-American, missed Kentucky’s first 17 games after injuring his left foot, a foot that he injured twice in high school, had to miss Kentucky’s five postseason wins, the SEC tournament and two in the NCAA Tournament with a sprained left ankle.
Recently he said the ankle was “70%” last week. Vanderbilt said he was only able to “practice a little bit” last week. Kentucky coach John Calipari said he was doubtful if he would play for the upcoming Kansas State game.

Foot and ankle injuries are very common in basketball. If you read my blogs I have written several articles on stress fractures. I encourage you to read them where I go into more detail, here I will just briefly touch on them.

ncaa3ncaa4 300x288Stress fractures

usually result from repetitive trauma or activity and overload to a bone of the foot until it fails. Most of us have days of recovery before we play again, but not for those who play at a high level. In basketball, the 5th metatarsal (the long bone just behind the little toe) is the usual place that gives due to the jumping and cutting on a court. Healing on average can take 4-6 weeks. We typically place our patients into a walking boot with limited activity.

Ankle sprains

can be different than broken bones and can even lead to longer recovery in some cases. They usually occur on the outside part of the ankle, where there are three big ligaments that hold the ankle together. When we roll our ankle we can stress the ligaments, partially tear, or even fully tear them. With most people the ligaments just get stressed and need to be immobilized first, then slowly worked out and strengthened. Sometimes, severe injuries do require surgery. With high level athletes, it is much more common to not get surgery due to the aggressive physical therapy and treatments typically only available to professional and high level college athletes. (The rest of us mere mortals don’t have as much access – another blog topic itself.)

Prevention of injuries is not guaranteed with high level basketball players, even with proper support and correction of any foot deformities or deficiencies. For the average player, wearing supportive and high quality foot wear, and properly recovering before putting more stress on your feet again will help prevent those common sport injuries.

Published in Blog
Friday, 23 February 2018 19:45

Compartment Syndrome in Runners

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Any runner who has been running for any decent amount of time will tell you they have been injured. Small injuries like muscle strains, knee pain, sprained ankles, capsulitis, bursitis, toe and toenail injuries are really common, while some runners may have even suffered large injuries like broken bones from missteps or falls. The list could go on, but we’ll keep this to the point. One injury that is starting to get more attention and research is Chronic Exertional Compartment Syndrome (CECS), which is a bit of a mouth full and can be debilitating for some athletes, especially runners.
*Note: this is not to be confused with Acute Compartment Syndrome, which is a surgical emergency, usually following severe trauma.

The classic presentation of CECS is often pain that initially begins as a dull ache in the lower leg (although you can also get this in the arms). As runners continue their training regimen, the pain increases to a level that they have to stop. Usually, stopping for a minute or two relieves the symptoms. The onset and degree of the pain can often become very reproducible and runners can almost predict exactly at which mile the symptoms will start.

CECS3 768x211The pain can be located in different areas of the lower leg (which we’ll define as being anywhere below the knee) or even both legs at the same time. It is usually a full or even cramping feeling in different compartments of the leg (we’ll get to the anatomy in a minute). The pain can also be accompanied by numbness, tingling, or just weakness in the ability to move the foot and ankle. This can even make it feel like the foot has become a numb bag of bones just flapping on the ground with each step.

ANATOMY

In an overly simplistic view of the anatomy of the lower leg, you can think of it as two long bones (your shin bone–the tibia–and another one you can forget) surrounded by muscles with tendons going down to the foot to make it move in all different directions. All of these muscles are enclosed in wrappers called fascia that hold the bundles together. (Think of it as being like tight cellophane around a few chicken breasts.) In the lower leg, there are four compartments. One in the front, one on the side, and two in the back (one deep and one not as deep).

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PHYSIOLOGY

Ok. So everything has its place, and does its job until, well, it doesn’t. That’s when it can go bad.
What exactly is happening with compartment syndrome in runners? We aren’t exactly sure, but we do know some of what is going on. The prevailing idea is that when you exercise, your muscles fill with blood, and when this expands and runs out of room (remember the chicken in the cellophane), it puts pressure on the small arterioles (small arteries) going into the muscle. This causes them to tighten down or even close off, decreasing their nutrient supply. Without oxygen and food, the muscles start “screaming,” and this equals pain. The numbness and tingling may be resultant of pressure on the nerves that run in each of those four compartments. (When you squeeze nerves, they either get numb or start causing pain.) In CECS, it is thought that there is more expansion of the muscles than the fascia wrapper will allow, causing pressure to build to this painful level. Some newer studies not yet published suggest there may be a component of deficiency of one of the major tendons (Tibialis anterior) that could predispose someone to this condition, but this may not account for the whole condition. Research is ongoing.

DIAGNOSIS

The gold standard to get the diagnosis of CECS involves a physician putting tubes into those different compartments and monitoring the pressure both while resting and while exercising. There are other emerging diagnostic imaging studies like MRI and Bone Scans which show promise, but for these, you’d have to rely on radiologists and physicians specialized to recognize the subtle changes that occur with CECS.

TREATMENT

Traditional treatment has been a fasciotomy (essentially cutting that cellophane wrapper). This can be done with large incisions, or with newer techniques that are minimally invasive. These treatments have shown about an 80% success rate. Other non-surgical treatments often tried, but with limited success, include: anti-inflammatory drugs, stretching, prolonged rest, ultrasound, electrical stimulation, orthotics, and massage. But one nonsurgical treatment may have promise.

CECS4 300x227Image from Wikipedia Commons

Changing Gait

There is research out of West Point that showed significant improvement in patients with CECS who transitioned to a forefoot strike gait. This was a small study, but the participants showed a dramatic decrease in pain and increases in their running distance of over 300%.

The thought is that this improved function lies in the difference in foot and knee position at ground contact. Other research has shown that anterior (front) compartment pressures are significantly influenced by running style — and anterior compartment pressures were significantly increased with a hindfoot-striking gait. So picture a full-knee extension combined with full ankle dorsiflexion (landing with your ankle bent and your foot up) at heel strike. Changing to a forefoot strike, like what is pictured below, may reduce the eccentric activity of the front compartment muscles, thereby reducing the pressure on this compartment.

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Chronic Exertional Compartment Syndrome is a condition not often brought up when talking about running injuries or problems, but might start gaining traction with running clubs. There is well documented evidence of improvement with surgery, but changes in gait may be effective in reducing symptoms without surgery. More research will shed light on the exact processes involved with this condition, and more nonsurgical treatments may possibly emerge.

Published in Blog
Friday, 16 February 2018 19:40

2018 Winter Olympics: Foot Problems Report

Winter Olympics and Foot Problems

David Collard DPM MHA

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As we are nearing the end of winter in some of the coldest weeks of the year, the 23rd Winter Olympics is in full force…and I’m loving every minute. If you are like me, you live for the Olympics and are captivated by the toughness, skill, passion, and the even the heartbreak of the athletes who put countless hours into their sport. Every two years, I feel like I can’t get enough.

To feed my temporary addiction, I looked a little closer at some of the athletes and their foot problems; in today’s blog post I’ll cover a few highlights of what can happen to the foot during sports and what it means for the future of these athletes.

Figure Skating

Figure Skating can be very hard on the feet and lead to injuries. Much like with other professional sports, some figure skating injuries can even end careers or limit top performance.

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Just before the U.S. Figure Skating Championships last year, Adam Rippon sprained his left ankle and fractured his fifth metatarsal bone in his left foot. The injury occured while hopping up and down to warm up his legs. His foot was immobilized. During his months-long recovery, he stated that he realized that much of the reason for the fracture was his poor diet. Adam admitted to trying to drop much of his weight with drastic dieting measures and eating meals very low in calories. He states he decided to change his diet because he suspected the unhealthy eating regimen had contributed to his injury. “I think I had a stress fracture before I broke my foot, and I think that was absolutely because I was not getting enough nutrients.”
The injury led to his withdrawal from the championships. His winning the US Nationals and now competing in the Olympics is his great return.

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Another well-known skater at the Olympics and a previous European champion, Russia’s Evgenia Medvedeva, had a similar metatarsal stress fracture in her right foot. This happened less than four months ago, leading into the Olympics. Medvedeva was placed into a cast to allow the bone to heal properly. Unfortunately, she was unable to skate for 2 months, missing both the Grand Prix and Russian Nationals. While immobilized, Zagitova, Medvedeva’s 15-year-old training partner and the World Junior champion, has shown to be a new Olympic power.

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Stress fractures are due to several factors, usually from low bone mass, deterioration of bone architecture, and fragile bones. Over time, the bone doesn’t respond well to normal mechanical stresses–like skating routines or simple warm-up exercises–and they crack. While many things can lead to stress fractures, in athletes this is usually tied to poor nutrition.

Snowboarding

Unfortunately, Katie Ormerod is out of the games this year with a fractured right heel. She is part of the Great Britain snowboarding team competing in Slopestyle. She is an upcoming star for Great Britain, having become the first Briton to win a World Cup big air title last year and also coming in third in slopestyle at the 2016 X Games in Aspen.

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She suffered this major injury on February 7th during a training session in Seoul, with only a few days before the opening ceremony. Katie exemplifies the toughness of these athletes, having fractured her wrist the day before while training. She had major foot surgery the following day to put the two pieces of her heel back together, which had been split in half. Healing from this type of injury can take several months with cast immobilization after the surgery and with gradual rehabilitation.

olympics5[Images found on Ormerod’s Facebook Page]

Sports and exercise are great for the body, but can be demanding at the highest levels, and sometimes accidents happen. But it is important to remember to have proper nutrition and eating enough calories and vitamins to build strong muscles and bones to keep you going. Remember to have the proper footwear for the sport! (I couldn’t resist.) Injures can put you down for weeks to even months. Take precautions and wear all safety equipment the sport demands so you can keep being active for many years to come. And, if you need me and I’m not in my office treating people, I’ll be in front of my TV watching the amazing athletes of the 2018 Games.

Published in Blog

OVERUSE INJURIES IN THE NEW YEAR

David Collard DPM MHA

As we ring in the new year and try to recover from all of the holiday cheer and food, many people are thinking about New Year’s resolutions–spending more time with family, drinking and/or smoking less, reading more, kicking other bad habits, etc. Many are resolving to do whatever they can to lose weight. (Sound familiar?) For long term results, though, the goal should really evolve from just weight-loss to leading a fit and healthy lifestyle. Losing weight WILL come along the way. I know, you want to get to a certain size or have the scale read a certain number. You can get there, but long-term fitness and health is so much more than a size and can be longer lasting. Being healthy and fit comes from long-term lifestyle changes with food and exercise, not just doing fad diets.

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A host of benefits can come along with these changes: increased energy, greater concentration and focus, greater happiness, improved memory, greater self-esteem, better sex life, longer and better quality of life, more ambition in your life, taking fewer or no medications, just to name a few. With this post, I hope to help you avoid the common mistakes that lead to foot and ankle injuries so you can achieve your goals and be injury free.

TOO MUCH TOO FAST

There are so many different exercises out there to improve your health and fitness. The most important step is to get up and get moving. Sometimes it’s not convenient or you’re too tired. I know, I work hard too and have a family, but from my own experience, I have never regretted going for a run or to the gym. Your body will thank you after!

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However, many of the injuries that occur when we start exercising at a high level are caused by doing too much too fast. In the medical world, these are called “overuse injuries.” We see them often in our clinic with people of all different sizes, ages, and experience. Running is one of the most common activities during which overuse injuries of the foot occur, but other overdone high impact exercises can also cause them. Remember, running isn’t necessarily where everyone should start. There are many other lower impact workouts that have huge benefits. (Think swimming, biking, elliptical, walking, etc.)

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Research shows us that overuse injuries occur as a result of too rapidly increasing: frequency, duration, distance (in running), and speed. Some studies report that people who stretch regularly before exercise experience a higher injury rate than those who do not stretch regularly, although others have not found an association between pre-exercise stretching and injuries. So the jury may still be out on stretching.

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Foot injuries can range from tendonitis and ligament tears to stress fractures. In children, we often see heel pain caused from irritation of the growth plate called Sever’s Calcaneal Apophysitis. Treatment for many of these overuse injuries is immobilization in a boot and sometimes even a cast.
 
Bottom line:

When you start to exercise, start with low intensity and frequency. Don’t be afraid to slow down at the beginning. Remember, this is a long-term change you’re trying to make, so you need to build a good foundation. And, in the case of running, DO NOT increase your mileage more than 10% per week. (Please don’t sign up for a marathon few months away if you have never run more than a mile or two!) Take it nice and easy. You’ll reach your goals eventually, and if you start noticing a pain in your feet early on, it may be best to back off for a bit and focus more on upper body.

Remember: you should always talk to your primary doctor before starting an exercise plan.

SHOES

Shoes are so important in all of this. In our clinic, we spend a significant part of our day educating people on proper shoes. If you are making the plunge to get healthy and fit, invest in a QUALITY pair of shoes. Using the least expensive ones you found online or in the big box store may seem like a great deal in the beginning, but is probably not supportive enough for the amount of activity you are starting and will likely land you in a chair in our office. Go to a reputable shoe store that has knowledgeable staff. The products may seem expensive at first, but you will likely be saving more money and time in the long run by remaining injury free.

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An average quality running/exercise shoe should be replaced after about 400 miles. But how much is that if you don’t keep a log or if running isn’t your exercise of choice? Replace your shoes when you start seeing creases in the outside of the sole of the shoe, when the bottom tread has worn out, or when the sole has become thinned out and lost its cushion. If you work out regularly, this should equate to about once every 6 months.

Finally, health and fitness is like climbing a large mountain. You can’t just sprint to the top. It takes planning, reassessing your path, making corrections, taking it slow and steady at the beginning, getting stronger the further you go. When you get to the top, the view is amazing, but doesn’t stop when you come back down!

If you or someone you know has is experiencing a foot or ankle injury that may be due to overuse, we are here to help. Please contact us and schedule an appointment. We want to get your feet back to health so you can get back to working on your New Year’s Resolutions.

Published in Blog
Thursday, 02 November 2017 13:42

Jones Fractures – Greg Olsen

If you are a Carolina Panthers fan, as so many are in the area where we practice, you may have heard that in September, the Panthers’ Pro Bowl tight end Greg Olsen suffered an injury to his right foot. During a Sunday afternoon game, Olsen was trying to cut when he suffered a Jones fracture to his right foot. He had surgery on it the next day and has been out of the game and recovering since then. Recently, his status has changed with the team, and he is now on injured reserve (IR). He recently told the Charlotte Observer if he didn’t get back on the field this season, “I’d be very surprised.” As fans eagerly await his return, many people want to know what a Jones fracture is and why so many athletes suffer them.

Jones fractures are a common foot fracture in sports and in the community, usually with athletes (or weekend warriors) who do cutting motions. They aren’t just in football though; many other types of athletes, including several great NBA players like Shaquille O’Neal and Kevin Durant, have also suffered Jones fractures. These injuries may just be a temporary setback for many high performance athletes, but in some cases, they can eventually end careers. They can also occur from tripping or twisting the foot (even something like falling into a small hole in the yard).

So what is a Jones fracture? Why is it such a big deal?

Hopefully we can help everyone understand what it is and how it is treated.

A Jones fracture is a fracture in the fifth metatarsal (a long bone on the outside middle part of the foot). You can get fractures in many different parts of that metatarsal, but the Jones is very specific. It is near the “base” of the bone (more toward the back) in an area that doesn’t have the best blood supply (red arrow).

 

Why is this area so important?

When healing injuries, especially bone injuries, blood flow is VERY important. The better the blood supply, the faster the healing. This fracture (break in the bone) occurs at an area that doesn’t have great blood supply and can therefore be the weakest part of the bone, making it a recipe for disaster.

Something else to consider is that, 1st metatarsal (yellow arrow) is much larger than the little 5th metatarsal (red arrow) where a Jones Fracture occurs. Our feet and knees work best when walking and running in a relatively straight line. Normally, the 1st metatarsal takes a huge amount of the load (it is bigger and stronger). But when you cut on the field or court, you have shifted most of the force onto that much smaller bone. Add in all the stuff about the blood supply, and this puts it at risk for not healing fast enough, or not at all (which we refer to as “nonunion”). But even without cutting, that bone helps to stabilize the outside of the foot with each step you take. This is why these injuries are so concerning.

What do we do about it?

In athletes, Jones fractures are usually fixed soon after the injury, in the operating room. A large screw is placed right down the middle of that bone (big screw for small bone that has poorer chance of healing), they are put in a cast for 4-6 weeks, after which they go through rehab, and are able to return to play after about 10 weeks. This is what Olsen had done, and similar treatment is often performed for many of the patients we see in our clinic.

But that isn’t the only way these injuries can be treated. Nonoperative treatment can be an option for some patients, but this requires being casted and not putting any weight on the foot for many weeks. Even then, there is a risk of not healing properly (nonunion).

 

Jones fractures aren’t always obvious injuries to people (unlike the “POP” and instant pain some experience with this or other fractures). Sometimes, there has been gradual onset of pain on the outside of their foot, and only after the pain becomes too much to bear or just doesn’t get any better, do patients come to see us. Sometimes, after several months, the infamous “nonunion” may already be present, meaning that the break in the bone doesn’t heal back together and you have a chronic broken bone. Yikes!

Hopefully now you have some insight into Jones fractures and why they have a reputation for being difficult to heal, even with proper and timely medical treatment. Olsen suffered a significant injury, but we will anticipate recovery and great things on the field!

If you or someone you know is experiencing an injury or pains that may indicate a Jones fracture, please contact us and schedule an appointment.

References:
Den Hartog, B D. Fracture of the Proximal Fifth Metatarsal. Journal of the American Academy of Orthopaedic Surgeons: July 2009; 17(7): 458–464.
Begly et al. Return to Play and Performance After Jones Fracture in National Basketball Association Athletes. Sports Health. 2016 Jul;8(4):342-6.
O’Malley et al. Operative Treatment of Fifth Metatarsal Jones Fractures (Zones II and III) in the NBA. Foot Ankle Int. 2016 May;37(5):488-500.
Hunt, Anderson. Treatment of Jones Fracture Nonunions and Refractures in the Elite Athlete
Outcomes of Intramedullary Screw Fixation With Bone Grafting. American Journal of Sports Medicine. 39(9): 1948-1954.
Roche, Calder. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. June 2013; 21(6): 1307–1315.
McBryde Jr., A M. The Complicated Jones Fracture, Including Revision and Malalignment. Foot and Ankle Clinics. June 2009; 14(2): 151-168.
charlotteobserver.com/sports

Published in Blog
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